(07HDC14286, 27 February 2009)

The family of a 40-year-old man
complained about the care he received from Southland District
Health Board (DHB). The man was a long-term client of mental health
services, and had a primary diagnosis of paranoid schizophrenia and
polydrug abuse. He was documented as being non-compliant with
medications and treatment, and having limited insight into his
condition. He lived an itinerant lifestyle and received psychiatric
care and treatment from a number of district health boards.

The man presented to the Southland
DHB acute mental health unit seeking admission. The consultant
psychiatrist conducted a brief assessment of the man, who then
became violent towards the consultant, resulting in the Police
being called and the man being detained. The psychiatrist reported
that when he assessed the man, he observed no evidence of
schizophrenia and assessed his behaviour that day as likely due to
antisocial and drug-seeking behaviour.

The man was assessed by two other
mental health professionals two days later on the order of the
court, and their opinion about his presentation was similar to that
of the consultant psychiatrist. A month later the man came to the
attention of the Dunedin police again and was admitted to Otago
DHB's Regional Forensic Psychiatry Service. A week later, he
underwent a mental state examination by a different consultant
psychiatrist, who determined that the man was suffering from
paranoid schizophrenia.

It was held that Southland DHB
breached Right 4(1) by not conducting an accurate and thorough
assessment of the man, which then influenced future handling of his
care by other providers within the DHB. Consultation with his
family did not occur, which meant that signs of relapse were missed
or treated as drug-induced anti-social behaviour, instead of his
primary illness of schizophrenia.

Furthermore, continuity between
providers coming into contact with the man was also poor. Failure
to use follow-up meetings to verify previous decisions, the DHB's
lack of coordination around his care, and the failure to share
relevant information with Otago DHB resulted in a breach of Right
4(5).